should be paid to the articles of food that are eaten, omitting first one, and then another, until the one by which the eruption is produced is ascertained. In chronic cases, the alkaline baths will often be found useful; or, occasional laxatives, the mineral acids, and vapor baths.

In the febrile form, particularly when occurring in robust, plethoric habits, leeches, or the lancet, will often be required, with saline purgatives, and nitre, a restricted diet, and the antiphlogistic regimen. generally.

When from a sudden disappearance of the eruption, sickness and pain of the stomach, or faintness, or symptoms of some local affection with an increase of the general febrile symptoms, and delirium or coma ensue in the first instance, the warm bath, sinapisms to the extremities, and small doses of ether or ammonia, will be required, and in the latter, bleeding, blisters, and pediluvia.

When urticaria occurs in debilitated constitutions, or when it assumes an intermittent type, the bark or sulphate of quinia must be prescribed. Should this fail, much benefit will, in many cases be obtained from the use of the solution of arsenite of potassa, given in small doses gradually increased.

8. Erysipelas.

The proper infantile erysipelas of medical writers is happily of unfrequent occurrence in this country. It may occur within a few days after birth, and usually, according to Hervieux (L' Union Med., 1855) within the first six weeks. In many instances, it is of intra-uterine origin. Although it seldom makes its appearance after the sixth week, still a few cases have been observed as late as the sixth or even twelfth month.

The invasion of the disease is often extremely insidious. The infant appears somewhat morose; his sleep is diminished and slightly disturbed, and he is less inclined to suck than before. With these trifling symptoms, there is associated a small patch of redness, usually on the lower parts of the body, particularly about the nates, pubes, groins, and umbilicus, which is painful upon pressure, and changes subsequently to a purplish or livid hue. In new-born infants, according to the observations of Meckel and Osiander, it is connected in a large number of cases with umbilical phlebitis.

Erysipelas may commence on any portion of the surface. According to Hervieux the order of frequency of its occurrence is upon the face, lower part of the trunk, and lower limbs, upper limbs, upper part of the trunk, scalp, and neck. As already remarked, we have seen it most frequently begin on the lower part of the trunk, and on the inferior extremities.

Erysipelatous inflammation spreads gradually and irregularly over the abdomen, along the back, and on the inside of the thighs. The parts occupied by it are swollen, hard, and extremely tender to the touch, as indicated by the movements and cries of the child. Generally, at the end of twenty-four hours, there arise upon the affected surface a few scattered vesicles, with inflamed livid bases, which may

terminate rapidly in gangrenous ulceration. The vesicles appear, in some cases, upon the first occurrence of the inflammation; in others, not until this has continued several days. Occasionally, vesication does not take place, and the disease is then of little danger or duration, the inflammation subsiding in two or three days. In those instances in which the inflammation is not very intense, it spreads rapidly in one direction, while it ceases in the parts originally affected; or suddenly disappearing at the part first attacked, it speedily reappears on some other, and, perhaps, remote portion of the surface, and in this manner, may successively invade every part of the skin.

In many cases, the skin surrounding the inflammation, to the distance of nearly an inch from its margin, is hard to the touch, and cannot be pinched up or moved over the subjacent parts, as in a state of health. In the majority of cases, this results from the infiltration with serum of the cellular membrane surrounding the inflammation.

When vesications appear early, the gangrene generally spreads rapidly, and the case soon acquires a very dangerous and hopeless character. This is more apt to be the case when the inflammation occurs upon the abdomen. On the extremities and nates it is more liable to terminate in deep-seated suppuration, with destruction of the subcutaneous cellular structure. When suppuration occurs, the pus is of a grayish color, and of a very thin sanious character; penetrating through the cellular membrane, beneath the skin, and between the muscles. Small portions of the skin finally slough off, and give exit to the confined matter, mixed with flocculi and large shreds of sphacelated cellular membrane. The genital organs, when the disease extends to them, sometimes sphacelate; in many cases they acquire an emphysematous appearance. In some rare instances the disease has been known to continue for fourteen or fifteen days, with but little vesication, and no diffused suppuration.

In the more violent form of the disease, the cessation of the gan. grene is marked, in the early stages, by a white line of demarcation. In the latter stages of the more protracted cases, it is by a secretion of healthy pus taking the place of the ichorous or sanious discharge. In many instances, erysipelas would appear to be at first a perfectly local affection; several days elapsing before any remarkable degree of general restlessness, crossness and fever presents itself.

In the early period of the disease, there is often considerable febrile reaction, which, upon the occurrence of vesication, assumes a low typhoid character. Upon the approach of suppuration, there is always more or less depression of the vital energies-though, in many cases, the tendency to sinking is evident from the commencement of the attack. Frequently the color and expression of the countenance remain for some days without exhibiting any striking change, when suddenly an ashy, cadaverous paleness is observed, the child cries incessantly; there is constant jactitation and complete loss of sleep, with a frequent pulse and increased heat of the skin. These symptoms are succeeded, more or less rapidly, by stupor and death.

Few cases occur in which the indications of gastro-intestinal disease are wholly absent. There is generally more or less tenderness of the

epigastrium-griping colicky pains-constipation, or frequent discharges from the bowels of a thin, grass-green fluid, preceded and accompanied with griping. Those portions of the surface of the body which are not occupied by the erysipelatous inflammation, often present a slightly jaundiced appearance, and the urine usually contains bile. Convulsions are not unfrequent.

The disease varies in its duration; it may run its course in a few days, or it may continue on to the end of the fourth or fifth week.

A very common form of erysipelas in infants, according to our experience, is that described by Dr. Friebe in the Journal for the Diseases of Children, under the name of Omphalitis exsudativa. It commences about the umbilicus, within a few weeks after birth, and is frequently accompanied with ulceration of that part, and infiltration of lymph or pus into the subcutaneous cellular tissue, and deposits of a similar nature within the partially obliterated umbilical vessels. It is attended by great and rapidly increasing exhaustion, and occasionally convulsive symptoms of more or less severity. It usually proves fatal; often within the course of forty-eight hours, and without having extended more than three fingers' breadth around the navel.

Dr. Friebe is inclined to view the disease as a variety of partial induration of the cellular tissue, in consequence of the cachectic condition of the infants in whom it occurs. The circumstance of the umbilical vessels being in part converted into fibrous cords, previously to the commencement of the disease, leads him to believe that it cannot arise from umbilical phlebitis. He appears to have seen but three cases. We have met with it much more frequently, always among the infants of the poor. Our observations have convinced us that, in the majority of cases at least, it is dependent upon phlebitis of the umbilical veins. The evidences of inflammation of the latter were unquestionably present in almost every instance in which we have made an examination. Trousseau remarks that the umbilical vein is often found inflamed and filled with pus, as far as the transverse furrow of the liver; while inflammatory exudations are found on the peritoneal surface of the abdominal viscera. In infants predisposed to erysipelas, he has observed that the umbilical cicatrix does not form readily; the ulceration which results being sometimes the occasional -the local-cause of the cutaneous disease.

In older and more robust children, erysipelas presents itself under the same forms as in the adult. A bright scarlet, shining efflorescence appears upon some portion of the skin, preceded for a day or two by heat, and a sense of tingling, and some degree of febrile reaction. The disease occasionally declines by the third or fourth day, the skin assuming a yellowish hue, and desquamating. In other instances, the disease runs a more protracted course. Vesications, more or less extensive, form upon the inflamed surface, which sometimes become filled with a purulent fluid. More commonly the vesications rupture in the course of two or three days, and give discharge to a thin, glutinous fluid. In other cases, the inflammation extends more deeply, and is attended with symptoms of greater severity. Rigors and severe febrile reaction precede the local disease, which is attended

with considerable swelling of an oedematous character. Suppuration early occurs, and a thin, purulent sanies is formed, which travels along the cellular structure, beneath the skin, and among the muscles and tendons, mixed often with clots of thin, grumous blood. The disease, unless energetically treated in its early stages, is now very liable to assume a gangrenous character, attended with great depression of the vital energies, and most commonly terminating in death. In the acute stage, inflammation of the cutaneous vessels is occasionally observed, and often purulent depositions take place in the serous cavities, and in the lungs.

In the examinations that have been made of infants who have died from erysipelas, phlebitis of the umbilical vessels has been frequently met with; we have observed it in the greater number of cases. Inflammation of the peritoneum, with puruloid or serous effusion into the cavity of the abdomen, is also commonly met with. Pleuritic inflammation, with effusion, is more rare. Pneumonia, vesicular, lobar, and lobular, is very frequent. Enteritis is one of the most common morbid appearances, although occasionally gastro-enteritis occurs.

Various opinions have been advanced in regard to the causes of infantile erysipelas. So far as our own observations extend, the disease would appear to originate, almost exclusively, in infants exposed to a confined and impure atmosphere, or in respect to whom proper attention is not paid to maintain a scrupulous cleanliness of their persons, bedding, and clothing-who are allowed to lie for hours with diapers imbued with excrement and urine, or, if their diapers are removed more frequently, having them hastily exchanged, without the surface being properly washed and dried, for others that have been worn already, and merely dried. Bad nutriment, no doubt, contributes, in the majority of cases, to the production of the disease.

Erysipelas of infants very commonly occurs during the prevalence of epidemic puerperal fever. Children of mothers who become affected with the fever, are often born with erysipelatous inflammation; others are attacked almost immediately after birth. Whether, in these cases, the disease is to be referred to a morbid matter applied to the skin in the womb, or to the same epidemic or endemic influence which gives rise to the disease of the parent, it is difficult to say. Trousseau, who has remarked that infantile erysipelas is principally observed when puerperal fever prevails in the wards of the lying-in hospitals of Paris, believes that the infants inherit from the mother a purulent diathesis, and seem to be still, within certain limits, subject to the same maladies as she.

The disease is one always of a very serious character. The larger number of young infants who are attacked by it die. Those of a more advanced age have a greater chance of recovery. The fatality of infantile erysipelas is influenced, to a great extent, according as we possess or not the ability to place the patients immediately under appropriate hygienic conditions.

In the treatment of erysipelas, as it occurs during infancy and early childhood, the nature of our remedies must be governed by the stage of the disease, and the character of the symptoms in each case,

In a large number of cases, every remedy of a debilitating character is strongly counter-indicated, and the early symptoms of prostration which present themselves force us at once to resort to such measures only as are calculated to support the patient's strength.

In every instance, it will be proper to pay attention, from the onset of the disease, to the condition of the bowels. A grain or two of calomel, followed in a few hours by a teaspoonful of castor oil, or laxative enemata, will be sufficient to procure a free evacuation of the intestines, without much irritation; they may be kept in a regular state subsequently, by the exhibition, every three hours, of divided doses of calomel, combined with ipecacuanha and extract of hyoscyamus'— the addition of the latter is calculated to prevent or allay irritation, without interfering with the aperient action of the other articles. When the skin is warm and dry, the liquor ammoniæ acetatis alone, or combined with antimonial wine, will often be found beneficial. Under the same circumstances, the occasional use of the warm or tepid bath will prove highly advantageous.

! R.-Calomel. gr. iij.—iv.
Ipecacuanhæ, gr. iij.

Carb. sodæ, gr. xij.

Ext. hyoscyami, gr. iv.—vj.—M.
f. ch. No. xij.

One for a dose.

2 R.-Liquor. acetat. ammon. Zij. Vin. antimonii, mxxxv.-xlv. Aq. cort. aurant. 3j.

Sacchar. puris, zij.-M.

Ten to thirty drops, every two or three hours, may be given.

If, with a hot and dry skin, there should occur symptoms of cerebral irritation, as intolerance of light, screaming, or convulsions, a leech or two should be applied to the temples, and cold applications to the scalp. The bowels should also be freely opened by castor oil, with the addition of turpentine, and warm pediluvia should be resorted to.

There cannot be a doubt that cases frequently occur in young children, which in their early stage are accompanied by symptoms that indicate the employment of local depletion, and that in these, a few leeches applied upon the sound skin in the neighborhood of the inflamed parts, will prove positively beneficial. We have repeatedly met with such cases, and proved the good effects of the practice. Much judgment, however, is required to discriminate the kind of cases which are likely to be benefited by local depletion, and to determine to what extent it may be prudently carried. As a general rule, a very moderate abstraction of blood will be sufficient.

When a tendency to gangrene is obvious, and the disease assumes a low, typhoid character, it will be necessary to resort, at once, to the use of carbonate of ammonia, in doses adapted to the age of the patient, and the urgency of the symptoms. At the same time, the child should be nourished at the breast of a healthy nurse, or, if weaned, its diet should consist of animal jellies dissolved in water, beef tea, chicken water, or sago. Where the symptoms of prostration are more considerable, we may combine the use of the ammonia with the sulphate of quinia, and the extract of hyoscyamus.

R.-Sulph. quiniæ, gr. ij.—iij.

Extract. hyoscyami, gr. ij.-iij.

Magnesia calcinat. gr. xxxvj.-M. f. ch. No. xij.
One to be given for a dose every two or three hours.